The document discusses polytrauma, Advanced Trauma Life Support (ATLS), and damage control surgery. It defines polytrauma as injuries to at least two body regions with an Abbreviated Injury Scale score of 3 or higher in conjunction with physiological abnormalities. ATLS involves assessing the airway, breathing, circulation, disability, and exposure during the primary survey to address life threats, followed by a secondary survey. Damage control surgery focuses on rapidly controlling hemorrhage, limiting contamination, and temporarily stabilizing fractures to prevent the triad of death from trauma before definitive care.

1. The University of Dodoma
School of Medicine and Dentistry (SoMD)
Orthopedics, traumatology and Neurosurgery
Polytrauma, ATLS and Triage in mass causality

2. ATLS
• A Advanced
• T Trauma
• L Life
• S Support

3. Definition
• Simultaneous diagnostic and therapeutic activities intended to
identify and treat life threatening injuries, beginning with the
most immediate.
• This focus on urgent problems is first captured by the " Golden
hour“ catch phrase and is one of the most important lessons of
ATLS.

4. Golden hour
• Injuries that threaten life during golden hour
– Airway obstruction
– Tension pneumothorax
– Open pneumothorax
– Massive hemothorax
– Cardiac temponade

5. Components
• Preparation and triage
• Primary Survey
• Resuscitation
• Adjuncts to primary survey and resuscitation
• Secondary survey
• Adjuncts to secondary survey
• Definitive care

6. Preparation
• Pre-hospital phase
– Receiving hospital is notified first.
– Send to the closest, appropriate facility.
• Hospital Phase
– Advanced planning for the trauma patient arrival.
– Method to summon extra medical assistance
– Transfer agreement with verified trauma center established.
– Protect from communicable disease.

7. • The used of the following protective devices is recommended
– Goggles
– Gloves
– Fluid-impervious gowns or aprons
– Shoes covers and fluid- impervious leggings
– Mask
– Head covering

8. Primary Survey
• A Airway
• B Breathing
• C Circulation
• D Disability (mini-neurological examination)
• E Exposure and environmental control

9. Primary Survey
• During the primary survey life threatening conditions are
identified and management is instituted SIMULTANEOUSLY

10. Airway
Always consider cervical spine injury
• Open airway
• Give oxygen
• Stabilize cervical spine

11. • Open airway
– Inspect tongue, foreign body
– Chin lift-head tilt
– Jaw thrust
– Suction
• Nasopharyngeal
• Oropharyngeal
– Intubation
• Endotracheal intubation
• Cricothyroidotomy

14. Airway adjuncts

15. Endotracheal tube

16. Intubation

17. • Indication For Definite Airway-(intubation)
– Unconscious
– GCS <8
– Severe maxillo-facial fracture
– Risk for aspiration : Bleeding/ vomiting
– Risk for obstruction : neck hematoma/laryngeal,tracheal
injury/ stridor
– Apnea : Neuromuscular paralysis/unconscious
– Inadequate respiratory effort:
tachypnea/hypoxia/hypercapnia/cyanosis
– Severe closed head injury

18. Breathing
• Airway patency does not assure adequate ventilation
• Inspection
– Engorged neck veins
– Trachea deviation
– Chest expansion
• Symmetrical and adequate
• Percussion
• Auscultation

19. Circulation
• Control external hemorrhage
• Check for Pulse rate, blood pressure, capillary refill, extremities
• Two IV large bore cannula
• Take blood sample for investigation
• Give bolus 2 litres of warm saline
– Children 20mls/kg

20. Disability
• AVPU
• Glasgow comma score (GCS)
• Pupils
– Equal size, reactive to light
• Lateralizing signs
• Movement of all extremities
– Upper and lower limbs
• Muscle power grade

21. AVPU scale
• A : Alert
• V : Responds to Vocal stimuli
• P : Responds to Painful stimuli
• U : Unresponsive to all stimuli

22. Glasgow Coma Score (GCS)
• Eye opening (E)-4
– Spontaneous 4
– To speech 3
– To pain 2
– None 1
• Best motor response (M)-6
– Obeys commands 6
– Localizes pain 5
– Normal flexion (withdrawal) 4
– Abnormal flexion (decorticate) 3
– Extension 2
– None (flaccid) 1
• Verbal response (V)-5
– Oriented 5
– Confused conversation 4
– Inappropriate words 3
– Incomprehensible sounds 2
– None 1

23. Exposure and environmental control
• Disrobe the patient
• Log roll maintaining axial traction
– Inspect back
– DRE
• Cover patient to keep warm

24. Resuscitation
• Oxygenation and ventilation
• Shock management, intravenous lines, warmed saline or
Ringer’s lactate solution
• Management of life-threatening problems identified in the
primary survey is continued

25. Adjuncts to primary survey and resuscitation
• Re-evaluate ABCDEs
• Electro-cardiographic Monitoring
• Nasogastric tube
• Urinary catheter
– Urethral injury should be suspected if
• Blood at the penile meatus
• Perineal ecchymosis
• Blood in the scrotum
• High riding or nonpalpable prostate
• Pelvic fracture
– Adult urine output 0.5ml/kg/hr
– Pediatric urine output 1mg/kg/hr
• Pain Management

26. • Monitoring
– Ventilatory rate & ABG
– Pulse oximetry
– Blood pressure
• X-Ray & Diagnostic Studies
– C-spine, CXR, Pelvic film
– Essential x-ray should not be avoided in a pregnant patient
• FAST

27. Secondary Survey
• Does not begin until the primary survey (ABCDEs) is
completed, resuscitative effort are well established & the
patient is demonstrating normalization of vital sign.
• Head to toe examination
• Complete history and physical examination
• Reassessment of all vital signs

28. • History
– A : Allergies.
– M : Medication currently used.
– P : Past illness/ Pregnancy.
– L : Last Meal
– E : Events/Environment related to the injury.
*blunt trauma/penetrating trauma/injuries due to cold &
burn/hazardous environment?

29. • Head to toe examination
– Head
• Raccoon’s eyes
• Rhinorrhea
• Nostrils
• Maxilla
• Mandible
– C spine
• Any area of tenderness
• Engorged neck veins
• Subcutaneous emphysema
• Trachea

32. • Chest
– Visual evaluation of anterior and posterior chest
• open pneumothorax
• flail chest
– Pain , dyspnea , hypoxia
– Cardiac tamponade , tension pneumothorax
• distended neck veins
• distant heart sound

33. • Abdomen
– Closed observation and frequent reevaluation
– Unexplained hypotension
– Equivocal abdominal finding

34. • Perineum/rectum/vagina
– contusion , hematoma , laceration , urethral bleeding
– rectal examination : blood , high-riding prostate, integrity of rectal
wall , sphincter tone
– female :
• Vaginal exam.: blood , laceration
• Pregnancy test

35. • Musculoskeletal
– Inspection : contusion , deformity
– Palpation : tenderness , abnormal movement
– Pelvic Fx : ecchymosis on iliac wings , pubis , labia, scrotum , pain on
palpation of pelvic ring
– Assessment of peripheral pulses
– Patient’s back examination

36. • Adjuncts to secondary survey
– Hemodynamic status
• CT scan
• Contrast x-ray studies
• Extremitry x-ray
• Endoscopy and ultrasonography

37. • Definitive care
– After identifying the patient’s injuries
– Managing life-threatening problems
– Obtaining special studies
• Transfer
– If the patient’s injuries exceed the institution’s treatment capabilities

38. TRIAGE
 Triage is the sorting of patients based on the need for treatment
and the available resources to provide that treatment.
 Color coding –
 Red(immediate/emergency) –patient requires immediate
management
 Yellow(urgent)-treatment can be delayed for a limited period of
time
 Green (delayed) –minor injuries such that treatment may be
delayed until other patients are stable
 Black –dead or severed injuries that are not expected to survive

39. TRIAGE IN MASS CAUSUALITY
• Multiple Casualties
– Number of severity & patient do not exceed the ability of the facility.
• Mass Casualties
– number & severity of patient EXCEED the capability of the facility &
staff.

40. MANAGEMENT OF
POLYTRAUMA

41. OBJECTIVES
By the end of this presentation students should be able:
1. To explain polytrauma
2. Describe ATLS
3. Describe management approach
4. To describe Damage control surgery

42. Polytrauma definition
 MONOTRAUMA
Injury to one body region
 MULTITRAUMA
Injury to more than one body region (not exceeding
Abbreviated Injury Score (AIS)≥3 in two regions) without
systemic inflammatory response syndrome (SIRS)

43. Polytrauma definition…..
POLYTRAUMA
Injury to at least two body regions with AIS≥ 3 in conjunction
with one or more of the listed physiologic parameters:
 Hypotension (SBP ≤ 90mmHg)
 Level of consciousness (GCS ≤ 8)
 Acidosis
 Coagulopathy (INR ≥ 1.4 or aPTT≥ 40s)
 Age (≥ 70years)

44.  Polytrauma is not synonym of multiple fractures.
 Multiple fractures are purely orthopedic problem as there is involvement
of skeletal system alone.
 While in Polytrauma there is involvement of more than one system,
Like associated head/spinal injury, chest injury, abdominal or pelvic injury.
 Polytrauma is a multi-system injury and needs management by
a team of surgeons and physicians.
 Orthopaedic surgeon is one of the team member of trauma unit.
POLYTRAUMA / MULTIPLE FRACTURES

45. The systemic inflammatory response
syndrome ( SIRS)
 SIRS describes the clinical presentation of patients with
systemic activation of the inflammatory response from any
underlying cause( Infection or trauma)
 As a consequence of SIRS, patients may develop multiple
organ dysfunction syndrome( MODS) and acute respiratory
distress syndrome (ARDS).
 The degree of SIRS following trauma is proportional to the
severity of injury.

46. Trauma scoring system
Purpose of scoring systems
 Appropriate triage and classification of trauma patients
 Predict outcomes (for patient and family counseling)
 Quality assurance
 Research
 – extremely useful for the study of outcomes

47. Classification Of Scoring Systems In
Trauma
Physiological Scores:
 Glasgow Coma Scale (GCS)
 Revised Trauma Score (RTS)
 Paediatric Trauma Score
 Acute Physiology and Chronic Health
Evaluation (APACHE)
 Systemic Inflammatory Response
Syndrome Score (SIRS)

48. Classification Of Scoring Systems In
Trauma……
Anatomical Scores:
 Abbreviated Injury Scale (AIS)
 Injury Severity Score (ISS)
 Anatomic Profile (AP)
 Penetrating Abdominal Trauma
Index (PATI)

49. Glasgow Coma Score
 The GCS is scored between 3 and 15, 3
being the worst, and 15 the best.
GCS is composed of three parameters :
 – Best Eye Response (4)
 – Best Verbal Response (5)
 – Best Motor Response (6)

50. Injury Severity Score (ISS)
The Injury Severity Score (ISS) is an established medical
score to assess
trauma severity.
 It correlates with mortality, morbidity and
hospitalization time after trauma.

51. Injury Severity Score (ISS)…..
 To calculate an ISS for an injured person, the
body is divided into six ISS body regions:
– Head or neck - including cervical spine
– Face - including the facial skeleton, nose, mouth, eyes and
ears
– Chest - thoracic spine and diaphragm
– Abdomen or pelvic contents - abdominal organs and lumbar
spine
– Extremities or pelvic girdle - pelvic skeleton

52. Injury Severity Score (ISS)…..
 Calculation is based upon the Abbreviated
Injury Scale (AIS) grades
0 - no injury
1 - minor
2 – moderate
3 - severe (not life-threatening)
4 - severe (life-threatening, survival probable)
5 - severe (critical, survival uncertain)
6 - maximal, possibly fatal

53. Injury Severity Score (ISS)…..
 ISS = sum of squares for the highest
 AIS grades in the three most severely
injured ISS body regions
 ISS = A2 + B2 + C2
 where A, B, C are the AIS scores of the
three most severely injured ISS body regions

54. Injury Severity Score (ISS)…..
 scores range from 1 to 75
 If an injury is assigned an AIS of 6
(unsurvivable injury), the ISS score is
automatically assigned to 75

56. Every team must have a final decision maker:
Management -TEAM APPROACH
Anesthetist.
General surgeon
Neurosurgeon
Orthopedic surgeon
A TEAM consists of:

57. Damage control surgery
 Damage control surgery (DCS) is a form of surgery
typically by trauma surgeons utilized in severe unstable
injuries.
 This form of surgery puts more emphasis on
preventing the triad of death, rather than
correcting the anatomy

58. Trauma triad of death
 Massive hemorrhage lead to :
 1. Hypothermia
 2. Metabolic acidosis
 3. Coagulopathy

60. Damage Control Surgery
(“STAGED LAPROTOMY”)
•Arrest bleeding , and the resulting coagulopathy.
• Limit contamination and the sequelae .
•Close the abdomen to limit heat and fluid loss,
and to protect viscera.
Damage control orthopaedics
1st stage temporary stabilisation of #
2nd stage resuscitation and optimisation
3rd stage definitive fracture fixation
•External fixator is most commonly used for temporary stabilisation
•Change to definitive # fixation is done latter